Alteration in Comfort: Pain

Alteration in Comfort: Pain

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Musculoskeletal disorder
(_) Visceral disorder
(_) Cancer
(_) Information
(_) Trauma
(_) Diagnostic test
(_) Immobility/improper positioning
(_) Pressure points
(_) Pregnancy
(_) Fear
(_) Anxiety/stress
(_) Overactivity
(_) Other:_____________________________
____________________________________
____________________________________

 

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Pt. reports or demonstrates discomfort.
Minor:
(
May be present)
(_) Autonomic response to acute pain:
  • increased BP, P, R
  • diaphoresis
  • dilated pupils
  • guarding
  • facial mask of pain
  • crying/moaning
  • abdominal heaviness
  • cutaneous irritation

 

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
  The patient will:

(_) Experience relief of pain A.E.B.

  • verbal reports of relief of pain
  • less autonomic responses to pain

(_) Other:

  (_) Asses characteristics of pain: location, severity on a scale of 1-10, type, frequency, precipitating factors, relief factors.

(_) Eliminate factors that precipitate pain: eg.:__________________
________________________

(_) Offer analgesics q___ hrs prn (according to physician order).

(_) Teach patient to request analgesics before pain becomes severe.

(_) Explore non-pharmacological methods for reducing pain/promoting comfort:

  • back rubs
  • slow rhythmic breathing
  • repositioning
  • diversional activities such as music, TV, etc.

(_) Other:________________
________________________
________________________
________________________

 

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature